Thursday, October 23, 2014

Surgical Intensive Care Unit

Posted by kamer234 at Thursday, October 23, 2014

It’s hard to believe that I have finished half of my rotations. It is one thing to know P4 year will go by quickly, and quite another to experience it!

So far I have completed my community, drug info, institutional, and surgical ICU rotation. I have had wonderful preceptors and experiences across the board, but I think the SICU tops the list. I worked with extremely complicated patients and was continuously exposed to new disease states and twists on familiar conditions. There was a steep learning curve, and it took me longer to feel comfortable on this rotation than any of the others because of the complexity inherent in each patient.

I started off the rotation following 2 patients and worked my way up to "owning" 10-12 and keeping tabs on the rest of the patients in the unit. One major plus of this rotation was the autonomy that Dr. Miller afforded me. I determined when I was ready to take on more patients.

My typical day started at 6 am when I began working up my patients. While working up patients I would look for medication related issues and would run it by either the resident or my preceptor prior to rounds. I would work up patients until rounds started shortly after 8am. Most days I rounded with the PGY2 resident or the pharmacist, but occasionally I would round by myself. Rounds on the SICU last anywhere between 3-4 hours, which can feel long some days, but I found that increasing my patient load helped keep my interest engaged. I also tried to listen for at least one unfamiliar condition, lab, drug side effect, etc per patient that I could look up later. 

My afternoons were spent reviewing patients, following up on questions, and one of my favorite parts of every rotation - topic discussion! I may be an outlier among my classmates, but I find topic discussion to be an efficient learning opportunity. In theory, it may sound similar to preparing for a therapeutics class or an exam, but in reality the material feels more practical and easier to remember after the topic. I find my learning to be facilitated by the opportunity to connect the topic to patients I see every day. 

My family and friends often asked if this rotation was difficult from an emotional perspective. During my 5 weeks in the ICU I saw many different types of patients and outcomes. While some cases were more difficult to face, most patients recover enough to leave the ICU, and there are a few patients who make the type of rapid recovery that refreshed my emotional stores. 

This rotation provided innumerable learning opportunities. This rotation is great for anyone looking to challenge themselves and learn a lot in a short amount of time. 

-Kallie Amer, PharmD Candidate 2015

Wednesday, October 22, 2014

Community Pharmacy in St. Ignace, MI

Posted by Unknown at Wednesday, October 22, 2014

Growing up in Southeastern Michigan, my family and I made many trips over the Mackinac Bridge into Michigan’s Upper Peninsula for vacation, recreation and exploring “Pure Michigan”.  However, this time over the bridge into St. Ignace was different.  It was time to move away from Ann Arbor to develop an understanding of how pharmacy operates in the Public Health Service and to experience the culture of a unique population, the Sault Tribe of Chippewa Indians. 

I woke up just after sunrise to make it to my first day of Rotation 2 at Mackinac Straits Health System working in the Tribal Pharmacy.  When I arrived at my site, I took a few moments to take in the scenery and saw this gorgeous view:

Immediately, I thought, “I could get used to this!”

After orientation to the pharmacy, clinic providers and systems, I started counseling patients as they picked up new prescriptions or inquired with questions.  On the second day, I began meeting with patients prior to their provider appointments in the Tribal Health Clinic.  These patients presented with either acute conditions or for chronic disease management.  During my time with the patients, I assessed vitals, reviewed medications, discussed concerns and ultimately made recommendations to the doctors or nurse practitioner after discussions with my preceptor.  Over the next five weeks, I spent about half of my time working and interacting with patients in the pharmacy and the other half of my time with patients and providers in the clinic.  This is a very unique practice setting aside from the traditional community pharmacy.  Here, the pharmacy is directly connected with the clinic, allowing for significant interprofessional collaboration and access to the patient’s medical and medication history and pertinent lab results.  This rotation and practice model allows for a unique blend of community and ambulatory care pharmacy in order to provide exceptional patient care.

On the afternoon of my first day, one of the clinic doctors posed a question regarding hallucinations and acute mental status changes in an elderly woman.  When this discussion started, I immediately associated the symptoms with a urinary tract infection (UTI) and sought the lab results from the urinalysis (UA).  The patient had documentation of a UTI two weeks earlier and completed a course of empiric therapy with ciprofloxacin approximately one week before returning to clinic.  Upon review of the results with my preceptor, we determined that the bacteria causing the UTI was resistant to ciprofloxacin.  The prescriber planned on extending the course of therapy with ciprofloxacin, but after reviewing the culture and sensitivities and performing a repeat UA, I recommended changing to an agent that the bacteria was sensitive to, nitrofurantoin.  Fast forwarding through the rotation, the patient’s UTI and symptoms resolved over time with this treatment.  As a student pharmacist early on in my Advanced Pharmacy Practice Experiences, it was extremely exciting to make a significant intervention and to impact patient care from the start of the rotation!

This sunset is from one of the last few nights as my rotation grew to a close.  While I only had the pleasure of working and learning at Sault Tribal Health and Human Services for five weeks of my last year of pharmacy school, I would go back in an instant!  I am so grateful to have had this community pharmacy experience to develop personally and professionally. 

P.S. The excellent providers and co-workers that I had the opportunity to work with and the gorgeous scenery are just an added bonus! 

-Jessica Fennelly, PharmD Candidate 2015

Tuesday, October 7, 2014

Rotation 1: It's a thin line...

Posted by Lauren Leader at Tuesday, October 07, 2014

... between bleeds and clots

MR is a 50 year old male who has had an LVAD machine since 2009. He presented to an outside hospital for management of continuous bleeding after severing a finger. The outside hospital held his warfarin and gave him a single dose of 5 mg of vitamin K, what do we do?

I spent my first rotation in ambulatory care specializing in anticoagulation. The service was a nurse run warfarin management facility with two pharmacists on staff. Pharmacists were specifically in charge of patients with LVAD (left-ventricular assist devices). These devices require more intense warfarin management due their increased risk of clotting. The majority of my time was spent monitoring patients INRs and having phone interviews to assess their regimen and make changes if necessary. The other valuable portion of this rotation was that the pharmacists on this service worked with the cardiology team to consult and follow TSOAC (target-specific oral anti-coagulants).


TSOACs are new medications and extremely useful medications. I was able to learn about the studies that the FDA used to approve these drugs, why one might be better for another give specific patient parameters and it was exciting to learn so in depth about something so new.

Also, on this rotation I had weekly meetings with other students on ambulatory care rotations throughout the health system. We had topic discussions, journal club meetings and case presentations which helped to increase our learning and prepare use for life-long learning opportunities in the field.

oh, the patient... almost forgot! We hardly ever give LVAD patients vitamin K since it directly inhibits the anticoagulation effects of warfarin and it is imperative that patients on LVAD machines stay anticoagulated. We gave him a two consecutive bolus doses of warfarin (one that day and one the next day) then restarted him on his previous maintenance dose. We were able to keep the patient from needing other forms of anticoagulation which was a win for everyone.

Rotation 3: Sleepless in Seattle (but it's a good thing)

Posted by Lauren Leader at Tuesday, October 07, 2014

Day 1: I woke up early to get to rotation by 9 am since I knew I would encounter traffic on the I-5 Southbound. Between watching the road and the GPS, I barely missed it. Right in front of me was a phenomenal view of Mt. Rainier. Seattle in late summer is void of its traditional rainy weather and is instead a beautiful, crisp 70 degrees, which lends to clear skies and amazing views from all around town. Enough about the city, for now. I arrived at the managed-care organization I would be working with and met my preceptor. We immediately started talking about the expectations for the rotation and what I would like to experience and what she would like me to accomplish. The list started out small. I knew I would like to get experiencing writing a drug-monograph, work with formulary management, answer drug-information questions and spend time at the help-desk assessing insurance claims. I thought that would be absolutely plenty to accomplish in the next 5 weeks. I met the team and the pharmacy residents I would be working with and set out to my first meeting to receive my first assignment. I met with the formulary coordinator and she said she had a drug monograph she would like me to write, now, never having written a drug monograph before I was extremely intimidated and concerned I would not be able to accomplish the task. The coordinator and I set goals for the different parts of the formulary and decided to meet weekly to review the sections, that made me feel MUCH more comfortable. I began to work on research for the monograph, when suddenly it was time for my second meeting of the day. I met with another team member in charge of prior authorizations. This company does formulary reviews every quarter and new prior authorization templates are typically required after each review. My task would be to create templates for the drugs that were new or needed to be updated. This was something I felt that I could accomplish much quicker and more easily. Eventually it was time to head home and this time I didn't miss a single bit of scenery.

Day 25: By the last day of rotation I never thought I would have completed as many projects and learned as much as I had. Not only did I muddle through, develop and present my own drug monograph, I was able to publish a nationwide article comparing the use of testosterone products and cardiovascular events, observe a statewide meeting to develop a standard protocol for prior authorizations among managed care organizations, assess pharmacist reporting and outcomes for MTM services and present the analysis to the pharmacists for improvement, make decisions on whether a particular drug should be covered for a patient, and of course experience the life and food of Seattle. As I think back on this rotation I am glad I took the opportunity to travel and I had so many more experiences than I could have ever imagined.